Stephen Church

WY BRITISH
TRANSPORT
POLICE

22 August 2014

Yeomanry House
131 Castle Hill
Reading
Berkshire
RG17TA

Aean Lin hecifotel,

Inquest into the death of Stephen Peter Church —
Report to prevent future deaths

| have been asked by the Chief Constable in his absence, to respond to your letter
dated 17" July in relation to the Regulation 28 Report highlighting concerns following
the inquest into the death of Stephen Church. You will appreciate that this tragic
incident occurred in 2011 and since that time the force has made great improvements
in how it deals with vulnerable people. We have received much praise for our suicide
prevention work and our partnership working in this field is pioneering in policing
terms.

With regards to the specific circumstances of Mr Church’s death | have instructed my
officers to review the matters of concern. I note that the second concern (of three)
does not relate to British Transport Police.

With regards to Concern 1: The chain of command within BTP was broken
unacceptably leading to only one police officer responsible for detaining Mr
Church.

rrived at the Royal Berkshire Hospital
about 11:45 with Mr Church. ii was assigned to a pre-arranged
operation later that day and needed to get to London to collect paraphernalia in
relation to that operation. He wanted to leave the hospital so that he could undertake

that task. About 12:10 telephoned the Duty Officer, Temporary
Inspecto and asked whether could be released.

 forrnec ET that Mr Church was not under the

British Transport Police
Force Headquarters, 25 Camden Road, London, NW1 9LN
email david.mccall@btp.pnn.police.uk direct 020 7830 8810 fax 020 7383 3023

BRITISH
> TRANSPORT
mes POLICE

influence of drink or drugs and was compliant. [refused the
request and instructed that both officers should remain. This message was conveyed
t

About 12:30 HE telephoned and s ntly sent_a text message
to his line manager at reacg as Millia. in fact off
duty at the time but authorised also by text message, to leave
the hospital. as not made aware of this development. As far

as he was aware both i remained at the hospital
with Mr Church.

At the inquest stated that he was not aware at that time that
had instructed both officers to remain at the hospital. He added
that had he been aware he would not have sanctioned
departure. conceded in evidence that the text message did in fact
include that information but at the time of agreeing to

ner ————
wee he had not read the entire text message, which included

| recognise that this breakdown in the chain of command ultimately had implications
for the care of Mr Church but | do not believe that this is a systematic failing in BTP
processes. Rather, this was an isolated incidence of misconduct. My Professional
Standards Department referred this incident to the Independent Police Complaints
Commission in 2011 and we currently await the outcome of that investigation. | will
ensure that any recommendations in relation to the actions of SN and
Ee are implemented and that any lessons learned are appropriately
promulgated throughout the force.

With regards to Concern 3: There was a lack of joint working amongst the BTP,
Royal Berkshire Hospital and psychiatric liaison service staff members to
ensure that Stephen Church was safe and the high risk of him self -harming
addressed promptly. There was a lack of appreciation amongst the psychiatric
liaison service, Royal Berkshire Hospital staff and BTP as to the importance of
contacting an approved mental health professional promptly to arrange a
mental health assessment.

| note that that Jury was concerned at the lack of joint working in respect of Mr
Church's detention and treatment. In particular:

British Transport Police
Force Headquarters, 25 Camden Road, London, NW1 9LN
email david.mccall@btp.pnn.police.uk direct 020 7830 8810 fax 020 7383 3023

TRANSPORT
POLICE

e No-one took responsibility for contacting the Approved Mental Health
Professional (AMHP).

e Hospital staff were not aware that BTP officers were with Mr Church and
believed them to be from Thames Valley Police.

e Only one of the BTP officers was aware that Mr Church had been assessed
as high risk of self harm.

e Staff were not aware that one officer was left alone with Mr Church.

| acknowledge that regular and detailed communication with the other agencies
involved in Mr Church's case could have led to his greater care whilst at the hospital.
Further, that additional care staff may have been provided had they been aware that
he was with only one officer. This issue of ‘proactively maintaining dialogue’ is
covered in the ‘Briefing Note — New Policy for London Section 136, (page 60) under
the heading ‘Triage Risk Assessment/Triage Psychiatric Assessment’. This element
of that briefing note is now included in all relevant BTP training.

| note that the Jury narrative highlighted the following points;

An approved Mental Health Professional should have been called, the fact that one
was not called contributed to Stephen Church's death for the following reasons;

e The protocol states that the AMHP should be called promptly

e Stephen Church was considered ‘High Risk’ by police and medical staff

e The Mental Health Act Codes of Practice clearly states that this is the next
step to a Section 136 detainee

e The delay left his mental health un-assessed

e The role of the AMHP was to coordinate the agencies and to provide clear
direction and this did not take place

The Inquest heard evidence that the single most important person to be informed
about the detention of a person under section 136 is the AMHP. The AMHP has the
ability and responsibility to coordinate all other agencies involved in the care of the
detainee. As soon as the AMHP is informed all other actions and processes in
respect of the care of the detainee can be expedited, thus reducing the amount of
time police need to remain at the place of safety.

The inquest heard evidence relating to the Mental Health Act, 1983, Code of Practice
especially in respect of paragraph 10.25 which states; (page 21)

British Transport Police
Force Headquarters, 25 Camden Road, London, NW1 9LN
email david.mccall@btp.pnn.police.uk direct 020 7830 8810 fax 020 7383 3023

ay TRANSPORT
POLICE

‘Where an individual is removed to a place of safety by the police, the following
recommendations apply:

e Where the place of safety is a hospital, the police should make immediate
contact with both the hospital and the LSSA (or the people arranging
AMHP services on its behalf) {my emphasis} and this contact should take
place prior to the person’s arrival at the place of safety. This will allow
arrangements to be made for the person to be interviewed and examined as
soon as possible.’

The ‘Interagency Joint Working Protocol for the Management of Mental Health,
Thames Valley Area’ (The Protocol) also deals with the procedure for calling an
AMHP. It states, (page 12)
‘The arresting officer will contact (via Control Room) the AMHP or the Emergency
Duty Team out of hours...’

It was acknowledged at the Inquest that British Transport Police was not a signatory
to the joint interagency protocol, but officers giving evidence accepted that they
would try to work to the aims where possible. | endorse this aspiration but must
highlight the impracticalities of British Transport Police being able to achieve this in
every case.

The recommendation that police should contact the AMHP in these circumstances
will always be problematic for British Transport Police. We do not routinely have lists
of available/on call AMHPs. This is information routinely known to health providers at
the places of safety and is likely to be subject of regular change and update,
sometimes at short notice. It would be impractical and problematic for a national
police force such as the BTP to hold this information and keep it up to date. To
attempt to do so could result in more confusion, risk and delay should officers require
to contact an AMHP prior to the subjects’ removal to a place of safety.

My view is supported by reference to a recent meeting of the Mental Health
Partnership Board for London, which includes CEOs of the London Mental Health
Trusts. At that meeting the question of whose role it was to call the AMHP following a
$136 detention delivered a unanimous response; that it was the role of the health
professionals as the police would not have access to up to date information. The
Board has recently launched a new policy for $136 and S135 arrangements in

British Transport Police
Force Headquarters, 25 Camden Road, London, NW1 9LN
email david.mccall@btp.pnn.police.uk direct 020 7830 8810 fax 020 7383 3023

BRITISH
TRANSPORT
POLICE

London (which was used to inform the Mental Health Crisis Care Concordat to which
BTP is one of the 22 national signatories). That policy does not recommend that
Police call the AMHP. The duty on Police is to call the place of safety coordinator
who is then responsible for making all necessary arrangements.

| am aware that the Mental Health Act Code of Practice is currently being reviewed
and a draft has been circulated for consultation. British Transport Police will be
asking for the recommendation for Police to call the AMHP prior to arrival at a place
of safety to be removed, as it is impractical and more likely to lead to confusion and
delay in provision of an early assessment for a patient in similar circumstances to Mr
Church.

| can assure you that British Transport Police is committed to providing the best
possible care to those vulnerable members of society who come to our notice. In
terms of the demand we face, | can tell you that in 2013/14, 631 people were directly
prevented from taking their own lives on the railway and removed from danger. Of
these the majority were detained under S136 of the Mental Health Act 1983 and
presented to a place of safety for assessment. In more general terms some 150
people per month are currently detained under S136 across BTP jurisdiction and | am
unaware of any repetition of the issues you have raised.

Whilst it would be a vast undertaking to be aware of each and every local protocol
from the 56 Statutory Mental Health Trusts and the 40 Mental Health Trust providers
in England and Wales, we are nevertheless in the process of detailing all ‘places of
safety’ on our Force Control Room Gazetteer to speed up the process of care for
Section 136 detainees.

| have committed training resources to front-litie officers in the following dreas:

e Exercise Jubilee — a Hydra (immersive training) exercise in relation to
vulnerable persons and those in Mental Health Crisis

e Suicide Prevention and Mental Health awareness — a one day classroom-
based programme for all officers around policies and processes as outlined in
the new manual of guidance

British Transport Police
Force Headquarters, 25 Camden Road, London, NW1 9LN
email david.mccall@btp.pnn.police.uk direct 020 7830 8810 fax 020 7383 3023

gy BRITISH
{p> TRANSPORT
ZirS POLICE

e A two hour input to all Force control room staff on Suicide Prevention and
Mental Health issues; the officer in charge of this training has been fully
briefed on the findings from Mr Church’s inquest and will incorporate the
lessons learned into this presentation

e All new officers receive a two hour input from the same officer and again the
lessons learned from Mr Church’s inquest will be incorporated

In summary, the break down in the chain of command is being addressed as a
conduct issue and | am confident that there is no systemic failing in this area. With
regards to the other concern highlighted, the BTP Manual of Guidance now includes
the following:

‘The original officers and those that may take over supervision of any detainee should
ensure that the person is not left alone or unsupervised until the responsibility for the
person is formally handed over to a medical professional for the process of
assessment and interview’.

In addition to this, the guidance now also makes clear that;

‘Attending officers and the senior nurse at the place of safety must consult...and
ensure that the relevant mental health doctor and AMHPs have been advised of the
persons status’.

1 feel confident therefore that the concerns highlighted at the Inquest have been
properly addressed by British Transport Police.

fee ent
a

a
Temporary Deputy Chief Constable

British Transport Police
Force Headquarters, 25 Camden Road, London, NW1 9LN
email david.mccall@btp.pnn.police.uk direct 020 7830 8810 fax 020 7383 3023

PRIVATE & CONFIDENTIAL
Peter J Bedford
HM Coroner Berkshire
Yeomanry House
DX: 40124 Reading Castle Street

Date: 23 October 2014

Royal Berkshire ffiX

NH5 Foundation Trust

Legal Services Department
Royal Berkshire Hospital
London Road
Reading
RG1 sAN

Tel: 0118 3227156
Fax: 01 18 3227047

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Our Ref: 
Your Ref:

h

Dear Mr Bedford

Re: Regulation 28 response in the matter of SC (Deceased)

The Trust has investigated and acted upon your concerns as set out in the Regulation 28 report to
prevent future deaths dated 10 July 2014.

Coroner's concerns

1.  The chain of command within the British Transport Police have broken unacceptably 

leading to

only one police officer responsible for detaining SC.

Z.  There was insutficient knowledge and understanding amongst members of the Psychiatric
Liaison Service and the Royal Berkshire Hospital as regards the interagency joined working
protocol for the management of mental health Thames Valley area.

3.  There was a  lack of joint working amongst the British Transport Police, Royal Berkshire
Hospital and Psychiatric Liaison Service staff members to ensure that SC was safe and the
high risk of him self-harming addressed promptly. There was a lack of appreciation amongst
the Psychiatric Liaison Service, Royal Berkshire Hospital statf and British Transport Police as
the importance of contacting an approved mental health professional promptly to arrange a
Mental Health Act assessment.

lnteragency meeting on 24 September 2014

ln order to address the coroner's concerns, there was a meeting at the Royal Berkshire Hospital in
Reading. In attendance were the following:

. 

. 

r 

 -  Director of  Nursing, Royal Berkshire NHS Foundation Trust, Corporate

Safeguarding Lead.

es -  Berkshirehealthcare NHS Foundation Trust

  Royal Berkshire NHS Foundation Trust , Mental Health Coordinator

 Royal Berkshire 

fW$ffi

NH5 Foundation Trust

. 

. 

r 

r 

. 

c 

. 

r 

r 

 -  Nurse Manager, Psychological Medicine Service, Berkshirehealthcare NHS

Foundation Trust

r -  Inspector, British Transport Police

   Approved Mental Health Practitioner (AMHP), Reading

   Consultant in the Psychological Medicine Service, Berkshirehealthcare NHS

NHS Foundation Trust

   Consultant in the A&E Department, Royal Berkshire NHS Foundation Trust

   Consultant in the A&E Department, Royal Berkshire NHS Foundation Trust

   Berkshirehealthcare NHS Foundation Trust

   Matron in the A&E Department, Royal Berkshire NHS Foundation Trust

The meeting was held to discuss the concerns raised by the coroner. With regards the first area of
concern, this is within the control of the British Transport Police and so we did not discuss it in any
depth. We understand a separate response has been sent.

At the inquest into SC's death on 1 July 2014 (the inquest), the coroner identified concerns regarding
an interagency protocol in use at the time. The protocol addresses a number of areas of inter-agency
interaction with mental Health patients in  the  Thames Valley.  lt  contains guidance on  the
management of section 136 patients under the Mental Health Act 1983 which was the area of concern
identified at the inquest.

A  revised version of the protocol is currently being finalised by Thames Valley Police under the
supervision of

, Inspector, Thames Valley Police, and Mental Health Lead"

s, Mental Health Act Administrator, is also assisting with the revision of the protocol. The
intention is for the protocol to be clearer and easier to understandlnavigate so that the agencies can
work together more effectively and are able to identify their individual roles with regards patients who
are admitted to the Trust under Section 136 of the Mental Health Act 1983.

-

There will be a consultation with all of the key members of the agencies including the senior A&E
e (mental health co-ordinator at the Trust)
consultants at the Royal Berkshire Hospita
and the Psychological Medicine Service (PMS). After the consultation the agencies will be required to
sign the protocol.

There will also be implementation of a training programme which again will be open to all of the
agencies that sign up to the protocol. British Transport Police are unable to sign local protocols
because they are a national force but they have agreed to abide by it.

The Royal Berkshire Hospital has drafted a flowchart to make the A&E staff more aware of the steps
that need to be taken in relation to Section 136 patients who are admitted to the accident and
emergency department (A&E).

At the meeting two classes of patients were identified. There are the patients who are admitted under
Section 136 and who are only intended to be at the Trust for acute medical care for a very short period
of time but then will be transferred to a place of safety such as Prospect Park Hospital and those like

 Roya| Berkshire WSP--S

NHS Foundation Trust

SC who need prolonged medical care and therefore are likely to be admitted under the Trust's care or
transferred to another acute Trust.

During the meeting one of the things which was identified as causing a difficulty and which may have
caused a difficulty when SC was admitted to the Trust was that there are six areas in the Reading area
who all have separate AMHPS. This complicates the process in that the individual informing the
AMHP of the need for their assistance when a Section 136 patient is identified is complicated by the
fact that the individual concerned needs to be able to identify where the individual patient was when
the Section 136 was applied. Depending on where they were physically at the time, a different AMHP
might be contacted. This causes some confusion in the system.

The flowchart will provide the A&E staff with a clear picture of the questions that they need to ask
when the Section 136 patient is admitted, in order to identify the appropriate AMHP so that they can
attend as quickly as possible which is not what happened in the case of SC. The contact numbers for
the 6 different areas will be included and the Trust will adopt the Sectionl36 monitoring form used by
the Mental Health Services.

There was also an agreement between all of the agencies that there should be closer working
together with shared information and assessment forms so that the process works much more safely
in the future,

Steps taken to address the individual concerns of the coroner are as follows:

1.  ln relation to the concern that there was insufficient knowledge and understanding amongst
members of the Psychiatric Liaison Service and the Royal Berkshire Hospital with regards the
interagency working protocol for the management of mental health in the Thames Valley area,
an interagency meeting was held on 24 September 2Q14 to identify the gaps in the various
agencies' knowledge and understanding with a plan put in place to revise the current protocol
and to  hold a  consultation. The protocol will be sent to  all senior staff involved in crisis
management of these patients and there will be training in the use of the protocol for all of the
agencles.

2.  The trust has a flowchart which identifies the steps that need to be taken from the point of
admission to A&E and identifies the role of the psychological medicine service (PMS) at the
Trust who will advise A&E on the management of the patient in the A&E Department. They will
also check that AMHP has been called which was a particular area of concern.

3.

4 .

The concern that there was a lack of joint working amongst the British Transport Police, Royal
Berkshire Hospital and Psychiatric Liaison Service staff members has been addressed by
putting in place a series of meetings between all the agencies involved and consulting over a
revised version of the protocol which will then be sent to all senior members of each agency. lt
will be sent to all those involved in crisis care.  There will be training on the use of the protocol
for all of the agencies who are to sign it including British Transport Police.

The lack of understanding as to the process and whose responsibility 
it is to callthe AMHP will
be addressed in three ways. The first is the amendment to the interagency protocol and that is
in an advanced state and will be sent for consultation at the beginning of November 2014.
There will be training across all of the agencies involved including Thames Valley Police, the
Royal Berkshire NHS Foundation Trust (A&E and Psychiatric Liaison Teams), the British
Transport Police and AMHPs in the Berkshire area. The Trust has drafted a flowchart that wil
be displayed prominently in the A&E department and will identify the process from admission of
a patient under a Section 136 to the A&E department to informing the AMHP and arranging for

 Royal Berkshire flm"Hffi

NHS Foundation Trust

the patient to be assessed with either admission to the Trust with support from PMS or a
transfer to a place of safety e.g. Prospect Park Hospital. The flowchart has been finalised and
approved by the A&E Clinical Governance Team. The Royal Berkshire NHS Foundation Trust
has also adopted the assessment forms for Section 136 monitoring from the mental health
Trust so that the key information is gathered on admission and the nursing staff are able to
identify whether the AMHP has been informed of the need for assessment at an early stage.
There will be a further check made by the PMS who will advise the A&E staff regarding the
management of the Section 136 patient in the A&E Department. PMS will also check whether
the AMHP has been contacted. Copies of the assessment form for Section 136 will be sent to
the RBH Mental Health Coordinator so that care can be audited.

5.  There is to be an emphasis on the importance of contacting an AMHP promptly which will be
communicated to  all A&E staff and all A&E staff will  be  aware that they must assume
for calling the AMHP and/or for checking that they have been contacted and that
responsibility 
they understand an urgent need to assess the Section 136 patient at the Trust as quickly as
possible. This is also one of the actions included on the flowchart which requires a senior
member of staff in A&E to ensure the AMHP has been contacted.

The timetable

The timetable for the above steps depends on the date when the amended protocol will be available
and will be sent out to  consultation. We  are advised that it  will be  completed and ready for
consultation at the beginning of November 2014.

ln the meantime, the Royal Berkshire NHS Foundation Trust has finalised and approved a flowchart
that will be prominently displayed in the A&E department. lt is intended that the flowchart will be in
place in the A&E department before 26 November 2014 and that staff will have received training with
regards use of the ftow chart and the s136 monitoring forms by the end of November 2014.

, and
In the meantime, the two senior consultants from the A&E departmen
ttended the inter-agency meeting at the Trust on 24 September and have
the Matro
taken the message back to the A&E department that there should be liaison with the PMS at the Trust
for the patient, will advise on their management and
who, although they will not take responsibility 
contacting the AMHP if that has not already been done. There is therefore a mechanism whereby the
A&E staff will be aware that it is their responsibility to check that the AMHP has been contacted and if
for any reason it is not done for the PMS to make sure that contact is made at the earliest opportunity.

ln summary, the interagency protocol has been finalised and will be sent out to all the agencies
involved for consultation at the beginning of November 2014. There has been a meeting between all
of the relevant agencies and another meeting is planned to discuss the revised protocol with training
for staff involved in crisis management to follow.

The A&E department has a flowchart which has been drafted in consultation with PMS and which
makes it clear that an AMHP needs to be called by a senior member of the A&E staff and that PMS
should be contacted to advise on management of the patient in A&E. The chart includes the numbers
of the 6 AMHPs in the Reading area and will be displayed prominently in A&E from 26 November 2014
at the latest. The Trust have adopted the Berkshire NHS Trust's Section 136 monitoring forms which
will encourage a consistent approach. They are to be used in conjunction with the flowchart and also
include the information that is needed on admission including whether the AMHP has already been
contacted.

 lf thc coronsr has any queriee regarding the Trust's r€$ponss plcaae contac

n

Royal Berkshire ffi
NHS Foundation Trust

Cc: The Chlef Coronsr

hy eles *)

a

THAMES VALLEY

Inspector

Force Mental Health Lead
Thames Valley Police Headquarters
Oxford Road

Kidlington

Oxon

a

06 August 2014

Mr P Bedford
Senior Coroner for Berkshire
- YeomanryHouse _--  __~ _ Loe _
131 Castle Hill
Reading Berkshire
RG17TA

Dear Mr Bedford.
Ref: PJB Church

| am writing in response to your request for explanation about what action
Thames Valley Police proposes to take following receipt of the Regulation 28
report from Assistant Coroner Mr Ravi Sidhu, who presided over the inquest
into the death of Mr Stephen Church.

Thames Valley Police were not directly involved in the original incident
involving Mr Church, his detention under S136 Mental Health Act nor his
subsequent care prior to his death on 13" May 2011. However, as the force
lead in Mental Health for Thames Valley Police | take responsibility for co-
ordinating the publication of an interagency joint working protocol for
managing mental health in the Thames Valley Area. This protocol was
subject to discussion during the inquest.

The interagency protocol is drafted in consultation with all the statutory
partner organisations and once completed is signed by the Chief Executives
or Heads of Service for each agency.

Re-drafting of the current protocol has been waiting for the publication of the
Crisis Care Concordat from the Department of Health and actually also the
findings of this inquest. The new draft relating to detention under $136 MHA is
now in the consultation phase and will take into account all the elements of
the incident that resulted in the death of Mr Church.

In addition to this the Chief Executive of Berkshire NHS Foundation Trust, Mr
Julian Emms, has already consulted with relevant organisations to agree a

local declaration and action plan to meet the expectations of the Crisis Care
Concordat. Thames Valley Police will be signatories to this declaration once
agreed.

The specific concern raised by Mr Sidhu that related to the protocol suggests
that there was insufficient knowledge and understanding about it among staff
members of the psychiatric liaison service and the Royal Berkshire Hospital.
Thames Valley Police has no direct responsibility or influence for their
understanding as responsibility for dissemination and training of the protocol
lies with the individual organisations concerned. However, once the amended
version has been agreed, Thames Valley Police is committed to work together
with the other organisations named within the Regulation 28 report to assist
with joint training and awareness. Our own staff will be informed of the need
to ensure that other organisations are aware of its existence whenever an
incident occurs and to support partner agencies in understanding the
individual responsibilities.

While British Transport Police have indicated that they are unable to be
signatories to individual protocols as they are a National Force, Thames
Valley Police will make every effort to ensure their awareness and
understanding of the Thames Valley protocol.

If you require any further information please do not hesitate to contact me.

Yours sincerely

Thames Valley Police Mental Health Lead